What are the effects of drug treatments for chronic tension-type headache?

BENEFICIAL

Amitriptyline. One systematic review and three small, short duration randomized controlled trials (RCTs) found that amitriptyline reduced the duration and frequency of chronic tension-type headache compared with placebo. One RCT found that amitriptyline was more effective than citalopram in improving headache duration, frequency, and severity. Another RCT found comparable effectiveness between amitriptyline and mirtazapine for the treatment of chronic tension-type headache, although amitriptyline was associated with a less favorable adverse effect profile. One RCT found no significant difference between amitriptyline and cognitive behavior therapy in headache scores or frequency of clinically important improvement after six months.

Mirtazapine (Only Short-term Evidence). One small RCT found that mirtazapine reduced the duration, frequency, and intensity of chronic tension-type headache compared with placebo. One RCT found comparable effectiveness between mirtazapine and amitriptyline for the treatment of chronic tension-type headache, although mirtazapine was associated with a more favorable adverse effect profile.

UNKNOWN EFFECTIVENESS

SSRI Antidepressants. One systematic review and one additional RCT provided insufficient evidence about the effects of selective serotonin reuptake inhibitors (SSRIs) on symptoms of chronic tension-type headache compared with placebo. One systematic review found no significant difference between SSRIs compared with amitriptyline for treatment of chronic tension-type headache; however, more adverse effects occurred in the amitriptyline group.

Tricyclic Antidepressants (Other Than Amitriptyline). We found insufficient evidence about the effects of tricyclic antidepressants other than amitriptyline.

LIKELY TO BE INEFFECTIVE OR HARMFUL

Benzodiazepines. Two RCTs provided insufficient evidence about the effects of benzodiazepines compared with placebo or other treatments. Benzodiazepines are commonly associated with adverse effects if taken regularly.

Botulinum Toxin. One systematic review and one subsequent RCT provided no evidence that botulinum toxin improved the symptoms of chronic tension-type headache compared with placebo. However, botulinum toxin is associated with important adverse effects.

Regular Acute Pain Relief Medication. We found no systematic review or RCTs. One nonsystematic review of observational studies provided insufficient evidence about the benefits of common analgesics in persons with chronic tension-type headache. It found that sustained and frequent use of some analgesics was associated with chronic headache and reduced the effectiveness of prophylactic treatment.

What are the effects of nondrug treatments for chronic tension-type headache?

LIKELY TO BE BENEFICIAL

Cognitive Behavior Therapy. One systematic review and one subsequent RCT found limited evidence that cognitive behavior therapy reduced the symptoms of chronic tension-type headache at six months compared with placebo. One RCT found no significant difference between cognitive behavior therapy and amitriptyline or in headache scores or frequency of clinically important improvement after six months. One systematic review provided insufficient evidence to compare cognitive behavior therapy versus relaxation or electromyographic biofeedback therapy.

UKNOWN EFFECTIVENESS

Acupuncture. Two systematic reviews and one subsequent RCT provided insufficient evidence about the effects of acupuncture compared with sham acupuncture in persons with chronic tension-type headache. A second subsequent RCT found that low-power laser acupuncture improved headache intensity, duration, and frequency compared with placebo.

Indian Head Massage. We found no systematic review or RCTs about the effects of Indian head massage in persons with chronic tension-type headache.

Relaxation and Electromyographic Biofeedback. Two systematic reviews and one subsequent RCT provided insufficient evidence about the effects of relaxation and electromyographic biofeedback on symptoms of chronic tension-type headache.

Definition

Chronic tension-type headache is a disorder that evolves from episodic tension-type headache, with daily or very frequent episodes lasting minutes to days.1 The 2004 International Headache Society criteria for chronic tension-type headache includes having headaches for 15 or more days a month (180 days per year) for at least three months; pain that is bilateral, pressing, or tightening in quality and that is nonpulsating, of mild or moderate intensity, and that does not worsen with routine physical activity such as walking or climbing stairs; presence of no more than one additional clinical feature (e.g., mild nausea, photophobia, phonophobia); and without moderate or severe nausea or vomiting.1 Chronic tension-type headache is generally regarded as a featureless headache. Not all experts agree that mild features more typically seen in migraine (e.g., photophobia, phonophobia) should be included in the operational definition of chronic tension-type headache, and it is often difficult to distinguish mild migraine headache from tension-type headache.

Chronic tension-type headache is to be distinguished from other causes of chronic daily headache that require different treatment strategies (e.g., new daily persistent headache, medication overuse headache, chronic migraine, hemicrania continua). Many persons who develop chronic daily headache owing to chronic migraine or medication overuse also develop mild migrainous “background” headaches that might be mistaken for coincidental chronic tension-type headache. It is therefore extremely important to take a full headache history to elicit the individual features of the headache and to look for prodromal or accompanying features that might indicate an alternative diagnosis.

In contrast to chronic tension-type headache, episodic tension-type headache can last for 30 minutes to seven days and occurs for fewer than 180 days a year. The greatest obstacle to studying tension-type headache is the lack of any single proven specific or reliable, clinical, or biological defining characteristic of the disorder. Terms based on assumed mechanisms (e.g., muscle contraction headache, tension headache) are not operationally defined. Older studies that used these terms may have included persons with many different types of headache.

Incidence and Prevalence

The prevalence of chronic daily headache from a survey of the general population in the United States was 4.1 percent; one half met the International Headache Society criteria for chronic tension-type headache.2 In a survey of 2,500 U.S. undergraduate students, the prevalence of chronic tension-type headache was 2 percent.3 The prevalence was 2.5 percent in a Danish population-based survey of 975 persons.4 One community-based survey in Singapore (2,096 persons from the general population) found that the prevalence was 1.8 percent in women and 0.9 percent in men.5

Etiology

Tension-type headache is more prevalent in women (65 percent of cases in one survey).6 Symptoms begin before 10 years of age in 15 percent of persons.7 There is a family history of some form of headache in 40 percent of persons with chronic tension-type headache,8 although a twin study found that the risk of headache was similar for identical and nonidentical twins.9

3. Rokicki LA,
Semenchuk EM,
Bruehl S,
et al.
An examination of the validity of the HIS classification system for migraine and tension-type headache in the college student population. Headache.
1999;39:720–7.

This is one in a series of chapters excerpted from Clinical Evidence, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of Clinical Evidence, as well as online at
http://www.clinicalevidence.com (subscription required). Those who receive a complimentary print copy of Clinical Evidence from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.